Customer Application – Sequoia Gas

Name*

First Middle Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Property Address*

Street Address Address Line 2 City State ZIP Code

Last 4 of Social Security Number

Date of Birth*

Driver's License #

Email*

Are You Interested in Receiving E-Statements

Yes
No

Home Phone

Cell Phone

Current Employer*

Work Phone*

Own or Rent*

Own
Rent

Landlord Name*

First Last

Landlord Phone*

Do you currently have propane?*

Yes
No

How much propane do you use annually?*

Is propane your main heating source?*

Yes
No

Which program do you prefer?*

Keep Full
Will Call

Spouse/Co-Applicant*

Yes
No

Spouse/Co-Applicant Name*

First Middle Last

Last 4 digits of Spouse/Co-Applicant's Social Security Number

Spouse/Co-Applicant Date of Birth*

Spouse/Co-Applicant Driver's License #

Spouse/Co-Applicant Phone*

Have the persons/business ever filed for bankruptcy?*

Yes
No

Date of Bankruptcy*

Previous Fuel/Utility Reference Name*

Previous Fuel/Utility Reference Phone

Bank Reference Name

Bank Reference City

Primary Checking Account Number

Authorization*

I agree to the authorization terms

By submitting this form, I authorize the above references and credit bureaus to release our financial information to Sequoia Gas Co.

The above information is given for the purpose of establishing an account and is a true statement. In consideration for the extension of credit, purchaser agrees to the terms of sale set forth on each invoice and/or contract. Purchaser agrees to pay a service charge on all outstanding balances at the monthly rate of 2% per our terms. In the event collection is needed, purchaser agrees to pay all costs.